MEDICARE: MS. DIANE R. MCNICKLE CRNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	TP005852C	PA

General Provider Information

NPI Number	:	1437267127
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. DIANE R. MCNICKLE CRNP

Provider Business Mailing Address
First Line	:	410 TOWER RD
Second Line	:
City	:	SELLERSVILLE
State	:	PA
Zip	:	18960-3128
Country	:	US
Telephone Number	:	215-453-7613
Fax Number	:

Provider Business Practice Location Address
First Line	:	1425 HORSHAM RD
Second Line	:
City	:	NORTH WALES
State	:	PA
Zip	:	19454-1320
Country	:	US
Telephone Number	:	215-371-6310
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/25/2006
Last Update Date	:	07/08/2014

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